INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Ocotber 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway/Greentree was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee # 8 was hired on January 4, 2018 and promoted as a counselor on June 2, 2019 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021. Employee # 8's record only document 20 hours and 45 minutes of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (f )(2) regulation by 11/25/22. They will sign off on their understanding of the requirement for yearly 25 clock hour training. The training coordinator will audit training hours for all staff monthly and send an updated training chart to the clinical managers and directors of each location.
During supervision, the clinical manager and/or director will review the monthly clock hours and document on the supervision form that the training hours were discussed.
Once a month, there will be a minimum of 2 hour all staff training at each location during a staff meeting to add to staff training hours for the year.
The clinical managers and directors will be educated by November 15, 2022 on the new training audit process and will be implemented by December 1, 2022. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee # 5 was hired as a counselor on June 30, 2018 and was still acting in that position. Employee #5 was reported to have 20 hours per week devoted to their 24 clients on their caseload.
The counselor Full Time equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility ' s work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 20/40=.5(FTE); 24/.5=48, which equals to a client/counselors ratios of 48:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All applicable staff will be trained on the Staffing Requirements Facility Summary Report and the Full Time Equivalent (FTE) for outpatient caseloads. This training will take place on December 1, 20222.
The OP Manager and Administrative Assistant will run weekly caseload/census reports. They will use these reports to ensure that the counselors caseloads are within the limits taking into consideration their hours works (average) and client's assigned to them.
Clients will be moved to another counselor if needed.
Audit of census reports and review of FTEs will begin on December 5, 2022 |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of two applicable records reviewed.
Client # 3 was admitted to the facility on January 10, 2022 and discharged on March 3, 2022. A treatment plan update was completed on January 27, 2022 and the next update was due no later than February 27, 2022; however there was no documentation of an update in the record.
Client #5 was admitted on April 25, 2022 and discharged on June 15, 2022. A comprehensive treatment plan was completed on April 28, 2022 and the next update was due no later than May 28, 2022; however, there was no documentation of an update in the record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical OP Director will immediately re-educate all staff at Greentree as to the parameters of the required Treatment Plan updates, to ensure all treatment plans are updated in a timely manner.
The OP Manager will monitor treatment plan updates with a monthly audit to review at least 50% of all required treatment plan updates.
The staff will be educated by November 30, 2022 and the treatment plan audit will be implemented December 1, 2022. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of the client records, the facility failed to ensure that the clients are receiving counseling services according to their individual comprehensive treatment plan in five out of five applicable client records reviewed.
Client # 3 was admitted to the facility on January 10, 2022 and discharged on March 3, 2022. The comprehensive treatment plan, dated January 27, 2022, indicated five group sessions per week and two individual sessions a week. The record of service and progress notes indicated that the client did not receive any individual sessions from January 30, 2022 through February 5, 2022.
Client #4 was admitted to the facility on March 10, 2022 and discharged on April 6, 2022. A comprehensive treatment plan, dated March 16, 2022, indicated five groups a week and two individual session a week. The record of service and progress notes indicated that the client did not receive any individual sessions from March 20, 2022 through March 26, 2022.
Client #5 was admitted to the facility on April 25, 2022 and was discharged on June 15, 2022. A comprehensive treatment plan, dated April 28, 2022, indicated five group sessions a week and two individual sessions a week. The record of service and progress notes indicated that the client did not receive any individual sessions between May 1, 2022 and May 7, 2022.
Client #6 was admitted to the facility on May 31, 2022 and discharged on June 22, 2022. A comprehensive treatment plan dated, June 15, 2022 indicated five groups a week and weekly individual sessions. The record of service and progress notes indicated that the client did not receive any individual sessions between June 12, 2022 and June 18, 2022.
Client #7 was admitted to the facility on June 20, 2022 and was discharged on July 15, 2022. A comprehensive treatment plan dated June 22, 2022 indicated five groups per week and two individual sessions a week. The record of service and progress notes indicated that the client did not receive any individual sessions from June 26, 2022 through July 2, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All applicable staff will be trained on the importance of following the treatment plan to ensure that the group sessions, individual therapy sessions, and treatment plan are connected in topic and the treatment program. The treatment plan will guide the treatment of the client.
Audit will be conducted weekly by OP Manager and Supervisor to ensure that the correct number of groups and individuals are being conducted to match the treatment plan.
If the services are not being completed according to the treatment plan, the OP Manager will discuss with the primary therapist in weekly supervision.
Audits will begin on November 28, 2022. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of the client records, the facility failed to ensure that the clients received individual counseling at least twice weekly in seven out of seven records reviewed.
Client # 1 was admitted to the facility on September 22, 2022 and was still active at the time of the inspection.
Client #2 was admitted to the facility on September 8, 2022 and was still active at the time of the inspection.
Client # 3 was admitted to the facility on January 10, 2022 and discharged on March 3, 2022.
Client #4 was admitted to the facility on March 10, 2022 and discharged on April 6, 2022.
Client #5 was admitted to the facility on April 25, 2022 and was discharged on June 15, 2022.
Client #6 was admitted to the facility on May 31, 2022 and discharged on June 22, 2022.
Client #7 was admitted to the facility on June 20, 2022 and was discharged on July 15, 2022.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All applicable staff will be trained on the requirements for partial clients by the OP Manager on December 5, 2022.
The OP Manager and the Supervisor will be completing weekly audits to ensure that all partial clients are receiving 2 individual sessions a week, per the regulation. Audits will begin on December 5, 2022.
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709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of two applicable records reviewed.
Client # 3 was admitted to the facility on January 10, 2022 and discharged on March 3, 2022.
Client #6 was admitted to the facility on May 31, 2022 and discharged on June 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical OP Director will immediately re-educate the OP Manager and Administrative Assistant at Allegheny Valley as to the parameters of the required follow-up regulation.
The OP Manager will monitor the consent for follow-up for all new admissions monthly to ensure that the Administrative Assistant knows which patients have consented for follow-up. The Administrative Assistant will track when the follow-up calls/letters need to be completed per the GRC policy. The OP Manager will conduct a monthly audit to ensure that the follow-up calls/letters are completed.
The OP Manager and Administrative Assistant will be educated by November 30, 2022, and the follow-up consent audit will begin December 1, 2022. The follow-up calls/letters audit will begin January 2, 2023. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare summary in one out of three applicable records reviewed.
Client #6 was admitted on July 27, 2022 and was discharged on September 14, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The OP Director will immediately re-educate all staff at Greentree on the licensing standard for Client Records and Aftercare Plans.
The OP Manager will conduct Case Consult meetings once a month in which Aftercare plans will be discussed in detail for upcoming discharges. The OP Manager will monitor Aftercare plans with a monthly audit to ensure that they are being completed per the licensure standard.
The OP Manager will be educated by November 21, 2022. The clinical team at Greentree will be educated by November 25, 2022. Meetings to discuss Aftercare planning will begin December 1, 2022 |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three applicable records reviewed.
Client #6 was admitted on July 27, 2022 and was discharged on September 14, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The OP Director will immediately re-educate all staff at Greentree on the licensing standard for Client Records and Discharge Summaries.
The OP Manager will monitor Discharge Summaries with a monthly audit to ensure that they are being completed per the licensure standard.
The OP Manager will be educated by November 21, 2022. The clinical team at Greentree will be educated by November 25, 2022. Audits will begin December 1, 2022. |